=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346993599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY EYECARE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2022
-----------------------------------------------------
Last Update Date | 02/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 PAGE BACON RD STE 13
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-243-2020
-----------------------------------------------------
Fax | 850-243-6555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 PAGE BACON RD STE 13
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-243-2020
-----------------------------------------------------
Fax | 850-243-6555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH M BAZARTE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 850-243-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------